Occupational health hazards of bidi workers and their families in India: a scoping review

Background Bidi workers and their families are exposed to harmful substances during bidi rolling, thereby jeopardising their health. We aimed to assess existing evidence on health conditions of bidi workers and their families in India. Methods We searched nine databases and relevant websites, and conducted citation screening to identify primary studies assessing occupational health hazards of bidi workers and their families. Two authors independently conducted screening and data extraction. We synthesised the findings narratively in a structured fashion. Results We found 3842 studies, out of which 95 studies met our eligibility criteria. High prevalence of disease conditions across all organ systems of the body was reported in bidi workers. Studies on female bidi workers showed decreased fertility (n=2), increased frequency of miscarriages (n=1) and higher risk of cervical cancer (n=1). Pregnant bidi workers were at an increased risk of anaemia and pregnancy-induced hypertension (n=2), higher frequency of neonatal deaths (n=1), stillbirths (n=1) and premature births (n=1) in comparison with non-bidi workers. Babies born to bidi workers reported low birth weight (n=5). Evidence from cohort studies suggests causal nature of the exposure to the disease condition. Conclusion Our review shows that bidi rolling leads to numerous occupational health hazards in bidi workers and their family members. It is essential to provide alternative livelihoods, and safe and protective working environment, and cover bidi workers under various social security provisions to alleviate the deleterious effect of bidi making at home. It is also important to shift bidi making away from home and strengthen existing regulations and promulgation of new provisions, including India’s Occupational Safety, Health, and Working Conditions Code 2020.

[5] This is indicative of increased absorption of tobacco during occupational exposure.
Other studies reported similar results with detectable levels of cotinine [(salivary = 0.84±0.26µg/ml and urinary = 0.09±0.03mmol/mol creatinine] in the saliva and urine of bidi workers.[2,6,9] Telomere dysfunction and DNA damage We found three studies assessing telomere length in bidi workers exposed to tobacco dust.[8,10,15] Telomere dysfunction is a marker of DNA damage with long term health consequences. 1 Bidi workers who worked singly in open courtyards 2 Bidi workers working in a poorly ventilated room BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Glob Health doi: 10.1136/bmjgh-2023-012413 :e012413.8 2023; BMJ Glob Health , et al.

Tyagi J
While one study reported that the average absolute telomere length/each chromosome end (kb) did not change significantly between bidi workers and control group [mean and SD = 0.75 ± 0.94 and 1.45 ± 2.76 kb; P=0.911] [10], the other two studies found that the comet and tail length of telomeres showed significant increase in bidi workers occupationally exposed to tobacco dust.[8,15] Nicotine induced oxidative stress We found one study evaluating the status of oxidants and antioxidants and their association with nicotine in bidi workers occupationally exposed to tobacco.[14] The study reported a significantly high level of oxidants, lipid peroxide in the form of MDA (p<0.001) and serum nitric oxide (NO) as nitrite (p <0.001) as compared to the controls [ MDA (nMol/ml) = 2.61 ± 0.25; (NO) = 55.5 ± 6.77 versus control (MDA )1.80 ± 0.48; (NO )49.14 ± 5.34; P<0.05]There was significant decline in the levels of antioxidants, erythrocytic-Superoxide Dismutase (RBC-SOD) (P<0.001),Vitamin-C (P<0.001) and total antioxidant capacity (TAC) (P<0.001) in bidi workers as compared to the matched controls.[14]

Chromosomal aberration
We found five studies evaluated chromosomal aberration in bidi workers and tobacco processors.[4,8,11,13,15] Bidi workers who were exposed to tobacco dust reported a significant increased chromosome aberration [mean and SD = 3.1±0.347versus 1.4±0.15;P<0.05] as compared to the controls.[15] Another study which was conducted on tobacco user bidi workers and non-user bidi workers reported similar results [mean and SD (non-user bidi workers 1.4 ± 0.25); P<0.0002 versus control 0.04 ± 0.04] [mean and SD (tobacco user bidi workers 1.97 ± 0.54); P<0.05 versus control 0.82 ± 0.28] when compared with non-tobacco user controls.[4]Others studies also reported bidi workers exposed to bidi tobacco dust significantly increased (P < 0.05) chromosome aberration in all age groups than that of age matched controls [8,11,13] indicating that occupational exposure to tobacco leads to a considerable genotoxicity among tobacco processors/ bidi workers.

Salivary sialic acid levels a pre-disposing factor of oral cancer
We found one study assessing the levels of sialic acid in bidi workers.[1] The study reported high salivary sialic acid level of bidi workers [mean and SD (mg/dL) =3.26 ± 5.00; 3.06 ± 6.0) as compared to no tobacco exposure.However, it was statistically non-significant.
Serum sialic acid is a sensitive tumour marker and increased levels might cause oral cancer.

Metal toxicity
We found one study assessing occupational exposure to toxic metals using fingernails of the bidi workers.[7] BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Glob Health doi: 10.1136/bmjgh-2023-012413 :e012413.8 2023; BMJ Glob Health , et al.

Tyagi J
The study reported higher levels of lead (44.2 μg g-1 ) in the fingernails of bidi workers as compared to other metals.In bidi workers Cd (3.86 μg g-1 ) and Cr (2.72 μg g -1 ) were particularly higher than the normal level (0.25 μg g-1 ) of control subject not exposed in occupational working environment.
Exposure to heavy metals could affect normal bodily function and could lead to chromium toxicity causing renal damage and increase cancer risk.[7]

Mutagenicity
We found two studies assessing urinary mutagenicity due to tobacco exposure in bidi workers with no tobacco habit and tobacco processors (no tobacco habit and masheri habit).[3,6] The study reported exposure to tobacco during bidi rolling resulted in an increased mutagenicity in TA98 in absence of metabolic activation, but no mutagenic activity was detected in TA100.This implies genotoxic hazard of occupational exposure to tobacco.[6] The majority of the urine samples from no tobacco habit and control were non-mutagenic in the presence or absence of S9 while those from masheri habit and controls were mutagenic to TA98 and TA102 strains upon metabolic activation.[3]This is indicative of exposure to occupational genotoxicants causing DNA damage and high risk of causing cancer.